Kachurek, David NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Idle Last Sex
David er Kachurek 114i7 Male
Date of Death Age If Veter U.S. Armed Forces,
03 / 02 / 2018 55 W- : rates N/A
Place of Death Hospital, Institution or
Z City, Town or Village Halfmoon Street Address 1103 Forest Lane
in Manner of Death❑Natural Cause 0 Accident 0 Homicide ®Suicide �Undetermined ®Pending
tii Circumstances Investigation
tia Medical Certifier Name Title
0 Daniel J. Kuhn Coroner
Address
40 McMaster St. , Ballston Spa. , NY 12020
Ni Death Certificate Filed District Number Register Number
City,Town or Village Halfmoon
>f Burial Date , Cemetery or Crematory
03 / 06/ 2018 Pine View Crematory _
>><®Entombment Address
'' ECremation Queensbury, NY
Date Place Removed
2❑Removal , and/or Held
and/or Address
Hold
Olt
0 Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
iigiEl Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iiI Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Ni Address
402 Maple Ave. , Saratoga Sp., NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
in
> Permission is h reb granted to dispose of the human rem ' s described above indicated.
Date Issued l Registrar of Vital Sta. tics 4
(signature)
District Number O�J J Place Ha fmoon , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z III Date of Disposition 3)'1 .w; Place of Disposition J:/ 4ta---
(address)
Cl,Di
lE (section) /A(lot number) (grave number)
IIName of Sexton or Person i0 Charge of Premises I{r.. c_ �"
Z (plelase print) • 1
Signature s /1 Title litic..
(over)
DOH-1555 (02/2004)